Provider Demographics
NPI:1174866164
Name:WIDMER, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WIDMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4669
Mailing Address - Country:US
Mailing Address - Phone:419-557-5541
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:3960 E HARBOR RD
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452
Practice Address - Country:US
Practice Address - Phone:419-732-0700
Practice Address - Fax:419-732-0702
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-011496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH428430Medicare PIN